Corneal Transplant

During the early postoperative period following a corneal transplant, a careful slit lamp exam is essential (Figure 7-1). The patient's epithelium will initially look irregular and may frequently be missing. The cornea will look swollen and probably have folds (generally 2+ to 3+) in the stro-ma. The junction of the donor and recipient bed will appear hazy and lumpy (there is often 1+ to 2+ swelling at the junction site). The anterior chamber may be somewhat shallow but should not be flat. It...

Patient Positioning

Photos Slit Lamp

Before positioning the patient, check to make sure that the slit lamp stage is locked in the position farthest away from the head support unit. Also, fold the tonometer arm completely out of the way if it was left in position. If the stage is not locked, the microscope may roll forward and bash the headrest unit, jarring the delicate optics and light system. If the tonometer arm is in position when the stage is not locked, and the slit lamp then rolls forward, the tonometer could hit the...

Refractive Surgery

Incisional refractive surgery is rarely performed for the correction of myopia at this time. The clinician will, however, encounter patients who underwent this procedure in the past. Upon slit lamp examination, one should notice milky thin radial incisions in the anterior to mid stroma (Figure 7-2). Once healed, they should not stain. Today, some surgeons still correct astigmatism with a form of AK (astigmatic keratectomy, Figure 7-3), using either limbal or corneal relaxing incisions. The most...

Cornea

The slit lamp was developed with the cornea in mind. The cornea is a curved transparent structure, much like the crystal on a watch. If you look at a watch glass while light is hitting its face straight on, the glass appears shiny and smooth. However if you view the glass with the light source coming from the side, at an angle, you can see scratches and pits. The slit lamp allows us to direct light onto the cornea from an angle. Use a full height, narrow beam at about 45 degrees, switching...

External Ocular Adnexa

External Adnexa

By definition, the ocular adnexa includes the lids, lacrimal system, orbit, and surrounding tissue (Figure 3-1). We will explore only those structures visible with the slit lamp. These external structures are screened with a moderately wide or full beam and 6X or 10X magnification. A beam angle of about 45 degrees is good, with the light directed from the left to examine the patient's lateral right eye and medial left eye, and directed from the right to examine the patient's lateral left eye...

Protocol and Documentation

It is important to develop your own slit lamp examination protocol. Performing the exam the same way, in the same order, on every patient, will increase the quality of your examination by ensuring that nothing is missed. Table 2-1 is a typical protocol. This protocol might be modified depending on the patient and the situation. For example, if the patient is uncooperative, select the structures that are most vital and examine them first. In addition, each examiner may modify this plan to suit...

Retroillumination

Slit Lamp Electronic Circuit

Retroillumination is used to evaluate the optical qualities of a structure. The light strikes the object of interest from a point behind the object and is then reflected back to the observer. Thus, it is similar to a silhouette. Some professionals advocate setting the slit beam slightly off center (via the slit scanning control ring or the slit centering knob) for these techniques. The authors prefer to leave the slit beam in its usual position. Direct Retroillumination From the Iris This...

TABLE 91 Soft Contact Lens Evaluation

Contact Lens Related Overuse Limbus

hygiene cleanliness look for deposits, film. Doc note, describe, grade 1+ to 4+ coverage generally, a soft contact lens will extend beyond the limbus in every direction the edge will not be on the cornea. Doc note, describe (limbal touch nasally, etc) movement a soft lens will generally move about 1.00 mm with a blink. If it does not, have the patient look up you should see a 1.00 mm downward slide of the lens. If it still does not move, have the patient blink while looking up there should now...

The Subjective Grading System

An important but confusing part of documenting abnormalities is the subjective grading system. Even the term subjective causes confusion because such grading occurs during the objective examination. Some clarification seems to be in order. First, many of the patient's symptoms are subjective. These are symptoms that the patient tells us about but that we cannot see, such as pain. Other findings are objective, which do not involve the patient's ability to report them. We can see them ourselves...

Arteriosclerosis arcus senilis

Asthma conjunctivitis, cataract (secondary to corticosteroid treatment). Bell's Palsy incomplete or absent lid closure, exposure keratitis. breast cancer metastatic lesion to angle, metastatic lesion to iris, other metastatic lesions (visible mass, redness), symptoms of metastatic lesions (exophthalmus, hyphema). cancer (see Breast Cancer, Colon Cancer, Leukemia, Lung Cancer, Melanoma). Candida albicans (yeast) swelling of lacrimal gland, lid thrush, conjunctivitis, stringy mucus, keratitis,...

Anterior Chamber Aqueous and Angle

Slit Lamp Angle Estimation

The anterior chamber of the eye is filled with a clear fluid called aqueous. The normal anterior chamber is optically empty. The aqueous that fills the anterior chamber is constantly being formed and drained out. The aqueous drainage area is found in the angle, the area formed where the posterior corneal surface meets the anterior iris root. (The angle itself cannot be viewed directly unless a gonio lens is used.) This dynamic creates a pressure within the eye, the IOP. Average IOP is around...

Specular Reflection

Specular Reflection Slit Lamp

Specular reflection is used to visualize the integrity of the corneal and lens surfaces. If the surface is smooth, the reflection will be smooth and regular if the surface is broken or rough, the reflection will likewise be irregular or appear to be textured. Its most common use is in evaluating the general appearance of the corneal endothelium. In this technique, position the illuminator about 30 degrees to one side and the microscope 30 degrees to the other side. The angle of the illuminator...

The Slit Lamp Primer

Eyesight Associates of Middle Georgia Warner Robins, Ga Series Editors Janice K. Ledford Ken Daniels Robert Campbell Delivering the best in health care information and education worldwide Copyright 2006 by SLACK Incorporated All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations...

TABLE 58 Types of Cataracts

Posterior Capsular Opacification Grading

Congenital (formed in utero or during infancy) 1. Polar Anterior or posterior (axial area) of the lens capsule appears as fine white dots Gray round opacities surrounded by a dark, clear zone can occur in pre- or postnatal development Presenile (formed during early childhood young adulthood) 1. Coronary Wreath of opacities in periphery of cortex Senile (appearance generally following ages 30 to 40) 1. Nuclear Sclerosis (NS) Lens nucleus normally hardens with age index of refraction of nucleus...

Measuring

Measuring the size of a finding can be an important part of the slit lamp examination. A record of a lesion's size from one exam to the next allows us to monitor for growth or resolution. Obviously, a lesion may be measured using a hand held ruler with one hand while observing through the slit lamp. Admittedly, this is awkward. It is far easier to use an ocular that has a ruler built in to the reticule. A third method is possible with vertical illumination source models. First, the slit is...

Instrumentation

The eye is one of the most fascinating structures of the body. A great deal of this fascination hinges on the fact that it is the only organ that we can look directly into without having to cut and or insert a special scope. The slit lamp is a microscope designed specifically to examine the eye. It is composed of a microscope and a light source. The microscope is binocular that is, it has two eyepieces, giving the binocular observer a stereoscopic 3-dimensional view of the eye. Thus, another...

Movement and Centration

Reverse Testicular Atrophy

A rigid lens is smaller than a soft lens and, thus, will not cover the cornea. The old PMMA hard contact lenses were designed to have an interpalpebral fit. That is, the centered lens lies entirely between the lids. The more modern method of fitting gas permeable lenses which are larger than PMMA contacts is the alignment fit, where the upper third of the lens stays under the upper lid Figure 9-7 . The movement of a rigid lens is much different from that of a soft lens. The rigid lens will move...

Slit Lamp Exam of the Prospective Contact Lens Patient

The result of the slit lamp examination is one of the determining factors in whether or not a patient can try contact lenses. Here is a basic list of things that the fitter will want to know 1. Tear film Is the tear film clear, or is there evidence of oil and or debris What is the tear BUT Is there evidence of dry eye 2. Eyelids What is the blink rate Do the lids close completely with each blink Are the lid margins smooth Is exophthalmus present Are the lids and lashes clean, or is there...

TABLE 55 Grading Corneal Staining

Narrow Angle Left Eye

Minimal superficial staining or stippling 1 Regional or diffuse punctate staining 2 Significant dense coalesced staining, corneal abrasion, or 3 foreign body tracks Severe abrasions gt 2.00 mm diameter, ulcerations, epithelial 4 loss, or full thickness abrasion Adapted from FDA document Premarket Notification Guidance Document for Daily Wear Contact Lenses. Figure 5-19. Herpetic dendrite. Photo by Val Sanders. Figure 5-20. Dry eye stained with rose bengal lower left quadrant . Photo by Val...

Ocular Diseases and Conditions

Some of the possible findings are admittedly rare. Some of the possible findings may be absent in a particular patient or case. See also notes on medications used to treat these conditions. blepharitis chalazion formation, collarettes, crusting matting, lid edema, lid erythema, froth, lash loss, lid notching, packed meibomian glands, trichiasis, decreased tear BUT, debris in tear film, matter, oily tear film, conjunctival dryness, conjunctival injection, stained corneal dry spots, punctate...

Iris Pupil

Spin Xray With Football Gear

atrophy Figure 5-25 - areas of thinned iris, iris may look moth eaten. If you shine the light straight back into the eye and get a red reflex, you can see red shining through the areas of atrophy in the iris. May occur from stretching tearing during surgery. Doc note, give location by the clock, draw coloboma - congenitally absent wedge of iris, from periphery into pupil. Is usually inferior. Doc note, may give location of opening by the clock, draw iris cyst Figure 5-26 - a translucent,...

Associated Problems Corneal Hypoxia

Contact Lens Staining Patterns

Corneal hypoxia lack of oxygen in rigid lenses often causes an area of edema that is central, rather than diffuse as in soft lenses. This central area is round or oval in the case of astigmatism , about 2.00 to 4.00 mm across, and grayish white. Draw or describe and grade any edema that is present. The edema becomes more dense as the condition worsens and may eventually be visible without the slit lamp. The problem may also be accompanied by superficial punctate corneal staining see Corneal...